A nurse is caring for a client who is 1 day postoperative following an open thoracotomy. The client is receiving oxygen mist at 40% by face tent. The client's SPO2 is 89-96%. ABG results are: pH 7.31, PaO2 93 mm Hg, PCO2 5O mm Hg, HCO3 25 mEq/L. Which of the following is an appropriate action by the nurse?
Position the client prone and have the respiratory therapist perform postural drainage.
Place the client in high-Fowler's position and encourage the use of incentive spirometer and coughing.
Increase oxygen to 70%.
Switch oxygen to a nonrebreather mask.
The Correct Answer is B
A. Prone positioning and postural drainage are typically not appropriate interventions for a client 1 day postoperative following an open thoracotomy, as this could place stress on the incision site and cause discomfort or injury.
B. High-Fowler's position facilitates lung expansion, which can improve ventilation and oxygenation. Encouraging the use of an incentive spirometer and promoting coughing helps clear secretions and expand the lungs, addressing the mild respiratory acidosis indicated by the ABG results (pH 7.31 and PaCO2 50 mm Hg).
C. Increasing oxygen to 70% is not appropriate, as the PaO2 level is within normal limits (93 mm Hg). The client's issue appears to be related more to ventilation (indicated by the elevated PaCO2) rather than oxygenation, so additional oxygen would not address the underlying cause and could lead to oxygen toxicity if used long-term.
D. A nonrebreather mask delivers a high concentration of oxygen, which is not necessary in this case since the client’s PaO2 is already adequate. The primary issue is not a lack of oxygen but rather the retention of CO2, so promoting ventilation and lung expansion through positioning and respiratory exercises is more appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Stage III pressure injury
Stage III pressure injuries involve full-thickness skin loss, extending into the subcutaneous tissue but not through the fascia. These wounds typically present as deep craters and may involve undermining or tunneling. Non-blanchable erythema alone without visible skin loss is not characteristic of a Stage III pressure injury.
B. Stage IV pressure injury
Stage IV pressure injuries are the most severe and involve full-thickness tissue loss with exposed bone, tendon, or muscle. These wounds often have extensive tissue damage and can be difficult to manage. Again, non-blanchable erythema without visible skin loss is not indicative of a Stage IV pressure injury.
C. Stage II pressure injury
Stage II pressure injuries involve partial-thickness skin loss with damage to the epidermis and possibly the dermis. These wounds often present as shallow open ulcers or blisters and may have characteristics such as intact or ruptured blisters. While Stage II injuries can present with erythema, non-blanchable erythema specifically indicates a Stage I injury.
D. Stage I pressure injury
Stage I pressure injuries are the earliest stage and involve non-blanchable erythema of intact skin. The skin may be warmer or cooler than surrounding tissue and may have changes in sensation. There is no visible skin loss at this stage, but the area is at risk for further injury if pressure is not relieved. Therefore, non-blanchable erythema on the heels most likely indicates a Stage I pressure injury.
Correct Answer is B
Explanation
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A. How many people live in your home?
This question pertains to social and environmental factors but is not directly related to assessing skin inflammation on the chest. While social factors can impact overall health, such as stress levels or exposure to infectious agents, the number of people living in the client's home is unlikely to be directly related to a new skin inflammation unless there are specific circumstances, such as sharing personal care products or close contact with others who have similar skin issues.
B. Did you have a recent exposure to irritants?
This question is highly relevant to assessing a new skin inflammation on the chest. Exposure to irritants or allergens can trigger or worsen skin conditions, such as contact dermatitis or allergic reactions. By asking about recent exposure to potential irritants like new detergents, soaps, fabrics, chemicals, or environmental factors, the nurse can gather important information to identify possible triggers for the skin inflammation.
C. Is nausea associated with your rash?
Nausea is typically not directly associated with a skin rash or inflammation unless there is a systemic condition or allergic reaction causing both symptoms. While it's important to assess for any systemic signs or symptoms that may be related to the skin condition, such as fever or malaise, specifically asking about nausea may not provide relevant information about the skin inflammation on the chest.
D. What is your body mass index?
Body mass index (BMI) is a measure of body weight relative to height and is not directly related to assessing a new skin inflammation on the chest. While obesity or changes in body weight can sometimes contribute to skin issues, such as friction-related dermatitis or hormonal changes affecting skin health, BMI alone is not a primary assessment parameter for localized skin conditions unless there are specific concerns related to weight-related skin problems.
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